Decubitus ulcers have plagued the nursing profession for many years as a major health care problem in term of patients’ pain, disfigurement, prolonged hospitalization and financial cost. Decubitus ulcers, commonly referred to as pressure ulcers, are the most preventable complication of intensive care units (ICU). Nurses, caring for patients in ICU, can exert a positive influence in prevention of pressure ulcer development by taking aggressive measures such as alleviating pressure, implementing meticulous skin care, and providing nutritional support.
A pressure ulcer is defined as “any lesion caused by unrelieved pressure that result in damage to underlying tissue; pressure ulcers are considered both inevitable and preventable” (Pokorny, Koldjeski, & Swanson, 2003, p. 535). Development of pressure ulcers confer significant morbidity and mortality to the critically ill patient and dramatically increase the cost of a medical bill. Research done at Mount Sinai School of Medicine in New York showed that the “cost of complications directly related to hospital acquired pressure ulcer average $225, 615 per patient” (Chronakos & Nierman, 2003, p. 365). Intensive care unit patients, especially the trauma patients, are among the highest risk groups. Chronakos and Nierman (2003) reported that “The incidence of decubitus ulcers average 10% to 15% in acutely hospitalized patients and increases to 30% to 60% in critically ill patients” (p. 365). Every patient in ICU is potentially at risk for developing pressure ulcers due to immobility, decreased sensory perception, low albumin levels, altered nutrition status and medications. Furthermore, many ICU patients have medical devices such as splints, cervical collars, casts and endotracheal tubes which have the potential to cause skin breakdown. Even though the issue of whether or not pressure ulcers are preventable in an ICU setting remains controversial, evidence-based practice suggests that with a systemic approach, the development of ulcers can be substantially decreased. It is the responsibility of each and every nurse to understand the extent and the cause of this problem so actions can be taken to avoid the complication or to treat it in initial stages when treatment is most effective.
Majority of ICU patients are limited in overall physical mobility, resulting in decreased ability to change their position in bed and thus increasing risk of prolonged and intense pressure. This is especially true for patients who are placed in a drug-induced coma because they are unable to communicate or change their position independently. Another frequently encountered problem in a critical care setting is the use of medications such as anesthetics and sedatives which alter sensory perception. All of these patients are enabled to consciously be aware of the damage being accumulated from pressure buildup; therefore, daily examinations of pelvic, sacral, elbow, scapula and heel areas should be an essential responsibly of a nurse. When soft tissue is compressed between external surface and a bony prominence for an extended period of time, the external pressure exceeds capillary pressure. As a result, blood flow becomes restricted; tissue becomes anoxic and release toxic metabolites causing cell death and formation of a pressure ulcer. Some of the signs that would demonstrate that there is skin breakdown are discoloration, warmth, edema and induration. However, methods that prevent patients from getting pressure ulcers is frequent examination and reposition which are based on research done by Chronakos and Nierman (2003), “cornerstones of care” (p. 365). Moreover, as stated by Chronakos and Nierman (2003), intermittent relief of pressure effectively minimizes tissue damage and can reduce the incidence of decubitus ulcers by seventy five percent (p. 368). For repositioning to be effective, the Pressure Ulcer Prevention Protocol states that patients should be repositioned at least every two hours to help alleviate pressure (Wurster, 2007, p. 269). Furthermore, nurses must be conscious to avoid shear and friction associated with positioning and transferring. Keast, Parslow, Houghton,
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and Fraser (2007), stated that “shear is the mechanical force that moves the bony structures in direction opposite to the overlaying skin” (p. 455). Therefore, particular attention should be directed in not placing patients directly on femoral trochanter and keeping bony prominences from direct contact with underlying surfaces by using pillows or foam wedges. For example, when the patient’s head is elevated, skin remains fixed against the bed linen but gravity pulls the skeleton towards the foot of the bed, which can cause distortion of capillaries, thrombosis and ischemia. Thus, to avoid injury, the head of the bed should not be elevated greater then thirty degrees. ICU patients present a challenge to this protocol due to the risk of aspiration and ventilator-associated pneumonia. These concerns should be balanced when caring for a seriously ill patient who is at risk for developing both pressure ulcers and aspiration pneumonia. Friction is another important aspect that needs to be considered when addressing pressure ulcers prevention. Friction or rubbing is defined as the force of two surfaces moving across one another, often resulting in abrasion. National Pressure Ulcer Advisory Panel recommends using bed linens to lift patients when turning or transferring to avoid dragging a patient who is physically weak (Chronakos & Nierman, 2003, p. 368). Additional beneficial tools used to reduce pressure are pressure-reducing mattresses, which help distribute weight evenly, specialized cushioning devices, and padding. However, studies done to identify types of mattresses to use for patients did not provide definite results. Though ultimately, it was concluded that “a patient who is judged to be at high risk for decubitus ulcers should not be placed on an ordinary hospital bed” (Chronakos & Nierman, 2003, p. 368).
Proper skin care for patients confined in bed for long periods is vital and must be done correctly. According to Chronakos and Nierman (2003), a moist environment increases the risk of pressure ulcer development fivefold (p. 369). Numerous factors such as fecal incontinence, leaking wounds, fever and perspiration due to higher ambient temperatures in the ICU may increase skin moisture and predispose patients to skin breakdown. In addition, moist skin is at increased risk for irritation, rashes and infections such as Candida. Wurster (2007) states that “skin care must be implemented by using a mild cleansing agent followed by thoroughly rinsing the skin with water” (p. 268). The use of warm water is recommended; dry the skin via patting and avoid using alcohol-based moisturizing agents to minimize drying and irritation. Keast et al. (2007) point out that fecal incontinence is a greater risk for skin breakdown than urinary incontinence because of the chemical irritation that results from the enzymes, which are caustic to the skin (p. 454). Therefore, to decrease the risk of developing an ulcer, the incontinence brief should be changed as soon as it becomes soiled. Frequent change of moist, soiled linen to promote evaporation and faster drying maintains dry, intact skin. Special attention should be given to trauma patients who require the use of cervical collars. Power, Daniels, McGuire and Hilbish (2006) report that “up to 55% of patients in a cervical collar for five days or greater develop skin breakdown” (p. 198). Research supports evidence showing that strict adherence to the standards of care, which include cleaning and assessing skin under the collar every twelve hours and changing the pads in the collar every twenty four hours, decrease the incidence of skin breakdown significantly. Care of wound drainage should be another factor to consider. Keast et al. (2007) recommends using appropriate dressings along with protective creams, ointments, films, and solid barrier sheets, such as hydrocolloids, to protect peri-wound skin from wound drainage (p. 454). When dressings have reached their maximum capacity for absorption they need to be replaced in order to prevent maceration of surrounding tissue. Pouching is also an option to control excessive exudates; if location of the wound permits.
Many ICU patients experience altered metabolism function, resulting in a poor nutritional state. Patients with major trauma, burns, and sepsis are particularly at increased risk for inadequate nutritional intake. An altered metabolism can lead to the loss of subcutaneous tissue, resulting in overexposed bony prominences and poor skin condition. Correction of nutritional deficiencies is very important for maintaining skin integrity. Albumin, the most abundant plasma protein, is responsible for the regulation of blood volume by maintaining osmotic pressure, and keeping the blood fluid from leaking out into the surrounding tissues. Thus, low serum albumin level can lead to interstitial edema which impedes the passage of nutrients from blood to the tissues. Studies have shown a significant correlation between levels of albumin and development of pressure ulcers. Chronakos and Nierman (2003) report that up to 75% of patients with albumin levels below 35g/L developed ulcers versus only 16% of patients with higher albumin levels (p. 367). Therefore, ICU patients must be assessed for nutritional deficiencies and proactive interventions should be implemented before malnutrition becomes severe. Wurster (2007), suggests that because nutrition is such an important element in wound prevention “adequate nutritional intake must be managed either by enteral or parenteral administration” (p. 269).
Pressure ulcers are considered a potentially preventable condition and many guidelines have been standardized and published to facilitate healthcare personnel in administering care. Yet current pressure ulcer prevalence and